2014 Inclusion Walk Registration Form **Registration is free; however, registration is required for all participants and must be completed by Friday, October 24

th to

guarantee each participant’s free t-shirt!

PLEASE FILL OUT A SEPARATE FORM FOR EACH FAMILY RESIDING AT A DIFFERENT ADDRESS Name: ___________________________________________________ Address:__________________________________________________ City: ___________________ State:______Zip:__________ Phone:______________________ Email: ________________________ TEAM NAME:___________________________________________________________________ Name of the child you are walking in honor of:____________________ Male:___ Female:____ (it could be your child that attends Brighton or any child that has inspired you!) Additional Family Member Names to be added to the Team Roster Family Member – First & Last Name:_________________________________________________ Family Member – First & Last Name:_________________________________________________ Family Member – First & Last Name:_________________________________________________ Family Member – First & Last Name:_________________________________________________ T-Shirt Order – Please select sizes for each walk attending the walk: Adult: S M L XL XXL 3X 4X Youth: Onesie(3-6M) Onesie(6-12) 2T 3T XS S M L # __ __ __ ___ ___ ___ ___ ________ _________ ___ ___ ___ __ ___ ___ In lieu of a registration fee, we encourage you to make a tax deductible contribution to support the programs and services of the Brighton Center that will go towards your Team’s Fundraising Total. Here's my tax deductible contribution (please circle):

$500 $250 $100 $50 $25 Other ___________ Please make checks payable to the Brighton Center or charge $_____ to my American Express, Visa, Mastercard or Discover Credit Card # _______________________________ Exp Date _________ 3 Digit Security Code ______ Name on Card _____________________ Signature _________________________

Waiver of Liability Walk Release This waiver must be included with registration. Registration is not valid unless signed. I, the undersigned, assume any and all risks that might be associated with the iWalk. I further waive,

release and discharge the Brighton Center, their officers, board members, sponsors, organizers, volunteers and other representatives of this event, for any and all injuries or damages of any kind whatsoever suffered by myself and/or my minor child(ren) as a result of taking part in the iWalk or related activity. I authorize the Brighton Center the use of any photo, film or videotape taken of me or my minor child(ren) at the event for the purpose of the Brighton Center. Signature __________________________________ Date ____________________